National Doctors Training & Planning
DEMAND FOR MEDICAL
CONSULTANTS AND
SPECIALISTS TO 2028 AND
THE TRAINING PIPELINE
TO MEET DEMAND:
A HIGH LEVEL STAKEHOLDER
INFORMED ANALYSIS
“Investing in the career development of doctors”
*This report represents the views of NDTP stakeholders rather than HSE or HSE NDTP itself.
ii
Authors:
Dr Roisin Morris, HSE NDTP Medical Workforce Planning Lead
Maeve Smith, HSE Medical Workforce Planning
National Doctors Training & Planning HSE Dublin
Copyright:
HSE – National Doctors Training & Planning 2020
Copies of this report can be obtained from:
National Doctors and Planning Health Service Executive Block 9e Sancton Wood Building Heuston South Quarter Saint Johns Road West Dublin 8
T: 076959924 E: [email protected] W: www.hse.ie/doctors
iii
TABLE OF CONTENTS
Foreword v
Introduction 1
1. Overview of Medical Workforce Planning within NDTP 3
2 Approach to Determining Demand 4
2.1 Context 4
2.2 Drivers of Change for Medical Workforce Planning 4
2.3 Future Forecasting: 5
2.4 Supply and Demand Gap Analysis 5
3 Working with Stakeholders 6
4 Data Use and Limitations 7
4.1 Data Sources 7
4.2 Demand Estimates 8
4.3 Private Sector 8
5 Profile of the Current Medical Consultant and Specialist Workforce 9
6 International Comparisons 17
7 Demand For Consultants And Specialists In Ireland 19
7.1 Estimated Demand For Medical Consultants And Specialists In Ireland 20
7.2 Analysis Of The Gap Between The Current And Future Supply And Demand For Consultants And Specialists in Ireland 24
7.3 Results 25
8 Training Implications Across Medical Specialties 29
9 Conclusion 31
9.1 How Findings Compare With Other Health Service Demand Related Reports 31
9.2 Ensuring A Self-Sustainable Medical Workforce 33
9.3 More Consultant-Delivered Care, Less Non-Training Nchds 33
9.4 A Final Word 35
10 References 36
11 Appendices 37
Appendix A Specialties/Stakeholders Engaged In The Medical Workforce Planning Process 37
Appendix - B Breakdown Of Demand For Consultants Working In Acute Medicine 39
Notes 41
iv
LIST OF TABLES
Table 5. 1 Estimated Consultant and Specialist Workforce in Ireland 2017/2018 11
Table 5. 2 Estimated Breakdown of the Consultant and Specialist Workforce in Ireland 2017/2018 - Medical Specialties
12
Table 5.3 Estimated Breakdown of the Consultant and Specialist Workforce in Ireland 2017/2018 - Surgical Specialties
13
Table 5. 4 Estimated Breakdown of the Consultant and Specialist Workforce in Ireland 2017/2018 - Other Specialties
14
Table 5.5 Total Number of HST Trainees per Specialty 2018 15
Table 6.1 Comparison of Ireland with international jurisdictions Total ratio per 100,000 of the Population
17
Table 6.2 Comparison of Ireland with international jurisdictions (Medical Specialties) Total ratio per 100,000 of the Population
18
Table 6.3 Comparison of Ireland with international jurisdictions (Surgical Specialties) Total ratio per 100,000 of the Population
18
Table 7.1 Drivers of Change to the Future Health and Medical Workforce 19
Table 7.1.1 Future Consultant/ Specialist Demand Estimates to 2028 21
Table 7.1.2 Future Consultant/ Specialist Demand Estimates to 2028 % Increase 22
Table 7.3.1a Scenario A Headcount Demand for Consultants in Paediatrics and Neonatology – Stakeholder Informed
25
Table 7.3.1b WTE Demand for Consultants in Paediatrics and Neonatology – Stakeholder Informed
26
Table 7.3.2a Scenario B Headcount Demand for Consultants in Paediatrics and Neonatology – Stakeholder Informed – 15% Emigration among newly qualified specialists
27
Table 7.3.2b Scenario B WTE Demand for Consultants in Paediatrics and Neonatology – Stakeholder Informed – 15% Emigration among newly qualified specialists
27
Table 8.1 Projected Training Needs to Meet Stakeholder Demand Estimates 29
Table 9.1 Demand Estimate Comparisons 32
LIST OF FIGURES
Figure 2.2 Drivers Of Change For Medical Workforce Planning 4
Figure 3.1 Stakeholders Involved in Medical Workforce Planning in NDTP 6
Figure 5.1 Training Pathway Through To Consultant Posts 16
Figure 7.1 Results of Gap Analysis All Medical Specialists and Consultants (excluding Psychiatry& Public Health)
28
Figure 7.2 Results of Gap Analysis Acute Hospital Based Consultants (excluding Psychiatry and Public Health)
28
Figure 7.3 Results of Gap Analysis General Practitioners 28
v
FOREWORD
Recruitment and retention of a sustainable medical workforce is a major challenge for healthcare systems
internationally, and Ireland is no exception.
The Irish medical workforce currently faces recruitment challenges, particularly at consultant level and in mental
health services and the smaller and less metropolitan model 2 and 3 hospitals. This has resulted in doctors who
are not on the Specialist Division of the register occupying consultant posts. Many consultant posts have failed to
attract any suitable applicants and remain unfilled.
There are also on-going and impending diThculties in the recruitment of General Practitioners.
The workforce in Ireland’s hospitals at NCHD level comprises approximately 50% training (excluding interns) and
50% non-training scheme doctors. The proportion of trainees relative to non-training scheme doctors should be
much higher. Other countries do not have such a high dependence on non-training scheme doctors to deliver clinical
service. Non-training scheme doctors do not have adequate training and career pathway opportunities and Irelands
over-reliance on this cohort of doctors has led to diThculties in adhering to the WHO Global Code of practice related
to ethical recruitment in health care and doctor migration.
NDTP believe that Ireland must develop a new vision of the medical workforce and to think again about how doctors
are best employed to provide high quality, sustainable patient-centred care.
Many initiatives to address these medical workforce challenges in the past have stalled for a variety of complex
reasons. With the energy brought to the transformation process by Sláintecare, there is now an opportunity to work
towards a more integrated, planned and sustainable medical workforce.
The analysis of the supply of, and demand for medical consultants, GPs and trainees across specialties in Ireland,
both public and private, as outlined in this report, represents a crucial stage in the process of optimising the Irish
medical workforce. The careful analysis of the data sources, engagement with stakeholders, specialised knowledge
and ability on behalf of Dr Roisin Morris, Medical Workforce Planning Lead, NDTP and her team, marks an important
step forward.
The consultant and trainee demand estimates outlined in this report will allow for better planning of the future
consultant, specialist and GP workforce to meet population healthcare needs and to align with proposed new
models of health service delivery. In parallel, they will allow for better alignment of postgraduate medical training
opportunities with the future predicted demand for medical practitioners.
I would like to express my sincere thanks and appreciation to all those who took the time to carefully consider
the future demand for specialists in Ireland across their field of medicine. The input of stakeholders, in particular
Postgraduate Training Bodies, Clinical Programmes and specialist professional bodies as well as medical
representative bodies, informed this report greatly. Estimates of future demand for specialists and trainees to
meet the future demand for patient care in Ireland, as outlined herein, are fully informed by these stakeholders.
I hope that the outputs of this report are used as a baseline to inform future changes to our health service and to
inform the development of a more fit-for-purpose medical workforce with a reduced ratio of non-training NCHDs to
both trainees and consultants.
Finally, I would like to thank Dr Roisin Morris and Maeve Smith along with all those who supported the development
of this report. Just like the medical workforce and Ireland’s health service, this is a dynamic piece of work which will
be updated as appropriate.
Yours Sincerely,
Professor Frank Murray MD
Director, National Doctors Training & Planning
1
INTRODUCTION
Evidence informed, medical workforce planning underpins senior strategic decision making within the HSE to ensure a
medical workforce that is fit for purpose to meet the population health needs of Ireland in the medium to longer term.
With this in mind, National Doctors Training and Planning (NDTP) works to develop appropriate, evidence informed
estimates to determine the annual numbers of medical trainees entering specialty training each year. Estimates are
based on longer term medical workforce projections derived from expert stakeholder consultation and statistical
modelling of medical workforce supply and demand data.
The drivers of change to the health service of the future have a major influence on medical workforce planning. These
include national health policies such as SláinteCare, Healthy Ireland, the development of Regional Integrated Care
Organisations, National Clinical Programmes and new models of care and service delivery; demographic changes;
evolving health service structures and recruitment and retention of doctors. These drivers of change are considered
in the medical workforce planning process.
The medical workforce in Ireland has faced many challenges over the years, not least in the area of recruitment and
retention of doctors. Ireland has one of the lowest levels of medical specialists in the OECD despite having one of
the highest levels of medical graduates (OECD, 2019) however it should be noted that these data are not directly
comparable as countries count and categorise doctors differently. In turn, Ireland faces great challenges in fulfilling
the WHO Global Code of Practice on ethical recruitment in healthcare.
This report was developed with a view to providing evidence around the current and future demand for consultant/
specialist doctors across medical specialties in Ireland, in order to inform postgraduate medical training and
consultant appointment requirements for the country to 2028. It also presents useful evidence to inform strategic
actions to address recruitment and retention issues across the consultant and NCHD workforce. It will also be of use
to doctors planning their careers and wishing to anticipate future opportunities.
All consultant workforce demand estimates presented have been informed by expert representatives of the
various medical specialties in Ireland. These include representatives and groups of representatives from Clinical
Programmes, Postgraduate Medical Training Bodies, HSEPrimary Care, HSEMental Health, specialty representative
organisations and others. These demand estimates do not necessarily represent the views of NDTP or the HSE, as
they are gathered from a wide range of stakeholder groups. Nonetheless, they are useful in establishing a picture of
where the major gaps in future medical workforce requirements are.
Many of these expert informed medical workforce demand estimates are derived from models of care developed
to map the strategic direction of certain medical specialties, for example Anaesthesiology, Paediatrics and
Neonatology, Palliative Medicine, Emergency Medicine and others. In General Practice, demand estimates are
derived through consideration of extending free GP care to larger cohorts of the Irish population, as well as to the
population as a whole. Other specialties use international workforce benchmarks to inform demand for consultants
and specialists within their field of medicine. Almost all demand estimates make an attempt at forecasting the
demand for specialists to address understaThng which has, for many, led to long waiting lists, an overreliance on
NCHDs, particularly non-training scheme doctors, to deliver care as well as onerous rostering arrangements.
In 2003, the report of the National Task Force on Medical StaThng, ‘the Hanly Report’ (Department of Health, 2003) outlined
the demand for medical consultants in order to improve delivery of care to patients, comply with the European Working
Time Directive (EWTD) and to develop a consultant-provided model of care delivery, as opposed to a consultant-led service.
Within this report, consideration is given to how the current consultant workforce compares with the recommended
consultant ratios per head of population for 2013 as outlined in the Hanly Report. That report recommended a doubling of
2
Consultant numbers, a Consultant to trainee ratio of approximately 2:1, and emphasised the need to assign Consultants to
a smaller number of hospitals open for acute admissions on a 24/7 basis. It is noted that the current consultant workforce
numbers in the main, still fall short of reaching Hanly recommendations, almost 17 years after publication. Furthermore, the
healthcare systems reliance on non-training scheme doctors has increased substantially, due in part to the requirement
to provide medical staff for and progress EWTD compliance in units which do not have the workload or capacity to
support assignment of large numbers of Consultants and trainees. In addition, a number of doctors delivering consultant
services within hospitals are not on the specialist division of the Medical Councils Register. Moving towards a consultant-
provided service with increased trainee numbers and a parallel decrease in the number of non-training scheme doctors,
as recommended in Hanly (2003) is discussed in the context of improving healthcare and working conditions for medics.
In recent years a number of important related reports have been published, outlining the future demand for health
services in Ireland. Among these are the ‘Sláintecare’ report (Houses of the Oireachtas 2017), the ESRI ‘Projections
of Demand for Healthcare in Ireland, 2015-2030’ report (Wren et al. 2017) and the Health Service Capacity Review,
2018 report (Department of Health 2018). The report ‘Securing the Future of Smaller Hospitals: A framework for
Development’ is also relevant to medical workforce planning (Department of Health and Health Service Executive,
2013). HSE NDTP has also published a number of medical workforce planning reports which outline demand for
specialists to meet future population health care needs. See www.hse.ie/doctors.
The ESRI report outlines projected increases in the demand for acute hospital and GP surgery based care activity,
based on factors related to population change and ageing. The impact of reconfiguration of services is not
considered. Within the Health Service Capacity Review, demand for healthcare is considered across both baseline
and reform scenarios. The baseline scenario projects a sharp rise in the capacity needed across all sectors of the
healthcare system by 2031. Conversely, full implementation of ‘reforms’ would result in decreased bed capacity
requirements with a higher increase in demand for primary care workers. While the findings of these reports are not
directly comparable with the projections outlined herein, they do offer context as well as valuable insights into how
to approach future planning research in terms of both utilisation of services and workforce requirements, in order
to better prepare for the introduction of Sláintecare. One recommendation of this report is to further evaluate the
impact of moving more care to the community with the demand for acute medical specialists, factoring in the current
onerous working conditions which stakeholders in the medical workforce planning process repeatedly pointed to as
an impediment to the delivery of eThcient and effective patient care. The results of these reports and how they align
with medical workforce planning findings outlined herein are discussed in Section 9 below.
Furthermore, the report ‘Securing the Future of Smaller Hospitals’ outlines how smaller hospitals should be
developed within the overarching structures of Hospital Groups to deliver appropriate, safe and effective care
at the lowest levels of complexity and closest to the patients’ home. In this way it outlines how less complex care
activity, chronic disease management for example, can be delivered within the context of the smaller, local hospital
infrastructure while more complex care is delivered in Model 3 and 4 hospitals.
Much needs to be done to increase consultant staThng levels across Ireland and indeed to ensure that hospital and
community work environments are attractive enough to make doctors choose to take up posts when advertised.
Within this report, expert informed recommended consultant/specialist numbers to staff both the public and private
healthcare sectors are presented to support decision making around aligning training numbers with the future
demand for medical consultants and specialists. However, it is appropriate to consider the fact that international
competition for medical staThng is intense and that it is not suThcient to focus solely on meeting future patient care
needs through training and appointing more consultant and specialist doctors. Going forward, more consideration
should be given to thinking outside the box in terms of ways of meeting the demand for medical staThng in our health
services and indeed better aligning the consultant workforce with the recommendations of Sláintecare. Among
other things, this should involve a focus on attracting medical staff to take up posts in services that have struggled
to recruit consultants and trainees and ensuring that all doctors are working to the top of their license thereby
ensuring eThcient use of medical resources.
3
1. OVERVIEW OF MEDICAL WORKFORCE PLANNING WITHIN NDTP
In 2014 NDTP fully incorporated Medical Workforce Planning (MWP) into its remit, with a view to bringing the number of
doctors in postgraduate medical training programmes in line with expert informed estimates of the future demand for
specialists in the health service, and, to inform the consultant appointments process. MWP within NDTP considers the
needs of service delivery across both the public and privately funded healthcare systems. Data on medical workforce
supply and demand are collected and analysed to inform postgraduate medical education and training decision making
i.e. around trainee intake numbers and allocation of funding, over a defined projection period.
Over the past 5 years NDTP have published a number of medical workforce reports, as well as a user guide to medical
and health workforce planning. These reports have informed decisions made at senior management level in relation
to numbers of required trainees per specialty to meet the future estimated demand for specialist doctors across
Ireland. For more information see www.hse.ie/doctors.
This report presents a multi-specialty analysis of medical workforce supply, demand and future training requirements.
It takes a high level analytical approach whereby specialty stakeholders have been consulted on an ongoing basis to
ensure their expert views on the future of each medical specialty are incorporated into the report findings.
Medical Workforce Planning (MWP) within NDTP is broadly based on the
following principles as per existing Government policies:
• In line with Sláintecare, more patient care should take place in the community and this should be reflected
in models of care for medical specialties. Work is ongoing across services to move more care into the
community, however much remains to be done
• The Irish health service should be self-suThcient in the production of medical graduates, with reduced
dependence on International Medical Graduates (IMGs)
• More patient care should be consultant-delivered and there should be a reversal in the ratio of Non-
Consultant Hospital Doctors (NCHDs) to consultants/ specialists
• MWP recommendations should be consistent with the WHO Global Code on the International
Recruitment of Healthcare Personnel (World Health Organisation 2010, 2011)
• MWP recommendations should encompass medical workforce requirements for the entire population to
include both the public and private healthcare systems
• MWP recommendations should incorporate future health needs of the population
• MWP recommendations should include the incorporation of projections relating to, for example,
demographic changes; alterations in disease incidence and prevalence; new models of clinical care;
medical and therapeutic innovations; policy initiatives and technological advances
• MWP recommendations should incorporate the implications of existing, and where known, future
healthcare policy (for example the Small Hospitals Framework; the National Cancer Control Programme;
Sláintecare)
• Trainee numbers for each specialty should be based on MWP projections for that specialty
• Training capacity should match the recommended training numbers. Where recommendations are made
to increase the intake of trainees into a particular specialty, additional training posts may be required
• Where appropriate, innovative models of care should be explored, for example new team structures, new
medical roles, skills transfer and task sharing
This report does not consider planning for non-training, non-consultant doctors. Work is ongoing within NDTP to
examine how this cohort of doctors can be better managed to improve the eThciency and effectiveness of the
medical workforce.
4
Recruitment and retention of medical
staThng including
doctor emigration
Government Policy e.g. SláinteCare
Current levels of unmet demand
Current levels of Service Utilisation
Drivers of change
to the future
medical workforce
New models of care
Technology and E-Health
Population ageing & Epidemiology
Service Reconfiguration
2 APPROACH TO DETERMINING DEMAND
The workforce model presented is broadly based on NDTPs MWP methodological framework ‘NDTP Health
Workforce Planning, Ireland: A Simple Stepwise Approach’ (HSE, National Doctors Training and Planning, 2016).
Typically, this methodology is applied to one medical specialty to determine the future medical workforce needs of
the country’s health system. In this case, the framework is used to guide the development of workforce and trainee
demand estimates to 2028 across all medical specialties. Due to the complexity of this task, the methodological
framework is used as a roadmap to determine high level need, rather than an in-depth review of workforce and
trainee demand over the next decade.
In following the stepwise approach to MWP, this chapter is broken down as follows:
2.1 CONTEXT
For the purpose of this report, a review of the configuration of the current workforce delivering all specialties of
medicine in Ireland, across both the public and private sectors of the health service, is included to infer the baseline
medical workforce as at 2017/2018 (see data explainer in Section 4).
2.2 DRIVERS OF CHANGE FOR MEDICAL WORKFORCE PLANNING
Consideration is given to the major drivers of change to the consultant and specialist workforce over a 10 -year
projection period i.e. to 2028. See Figure 2.2.
FIGURE 2.2 Drivers Of Change For Medical Workforce Planning
5
2.3 FUTURE FORECASTING:
In order to determine future demand for medical consultants and specialists, NDTP engaged with major stakeholders
representing all specialties of medicine including for example, National Clinical Programmes (NCPs), Postgraduate
Medical Training Bodies, Specialty Representative Bodies, the Department of Health (DoH), HSE and others.
Stakeholders were asked to indicate to NDTP what the future demand for consultants/ specialists in their area of
medicine was and the rationale underpinning the demand estimates. See Appendix A for a list of stakeholders.
International healthcare systems staThng levels were also reviewed. Consideration was given to the Report of
the National Taskforce on Medical StaThng (Department of Health, 2003). While this report may seem dated,
recommendations were due to be in place by 2013 and, as can be seen in section, many of the recommendations
of the report are yet to be met. It should be noted that projections made in the Hanly report were to meet service
delivery as envisioned in 2013 and can therefore only be used as a baseline rather than a robust ratio for evaluating
service demand in 2028.
2.4 SUPPLY AND DEMAND GAP ANALYSIS
This part of the workforce planning process involved consideration of all data gathered on the current supply and
future demand for the workforce. A workforce stock and flow gap analysis was run to determine the future gap
between the demand for and the supply of workers over the 10-year projection period. This analysis was run for
stakeholder informed demand estimates on a specialty by specialty basis and was useful in informing the future
training pipeline required over the next decade.
It is important to note that analysis was kept at a high level for this particular report albeit that the statistical
model can be altered to determine the impact of different external drivers to include emigration of newly qualified
professionals, feminisation of the workforce, a reduction in education places and re-entrants into the workforce,
among other things. An overview of the statistical modelling methodology used can be found in the report, ‘A
quantitative Tool for Workforce Planning in Healthcare’ (Behan et al. 2009).
6
Private
Sector
Clinical Programmes
Training
Bodies
Medical
Council of Ireland
Acute
Hospitals
HSE WPAI/
BIU
Medical Workforce
NDTP CHOs/HGs
Planning
CSO DoH
Primary
Care
Specialty
Groups
Mental
Health Patients Division
3 WORKING WITH STAKEHOLDERS
Over time, NDTP has engaged with multiple medical workforce planning stakeholders, representing all medical
specialties, with a view to appropriately representing stakeholder views on the future demand for consultants and
specialists in Ireland. Stakeholders engaged in this process include relevant National Clinical Programme Leads,
Postgraduate Medical Training Bodies, relevant senior administrators in the HSE, the Department of Health (DoH),
relevant specialty representative groups and the Medical Council of Ireland. Key stakeholders in medical workforce
planning in general are represented in Figure 3.1.
FIGURE 3.1 Stakeholders Involved in Medical Workforce Planning in NDTP
7
4 DATA USE AND LIMITATIONS
It is important to outline a number of caveats attached to the analysis of consultant and specialist workforce and
trainee requirements outlined herein. These include the following:
4.1 DATA SOURCES
The data utilised in the analysis of the medical workforce in each specialty for these reviews are
drawn from multiple sources, all of which have richness as well as limitations, as follows;
• HSE NDTP Doctors Integrated Management E-System (DIME), which receives data from the
Postgraduate Medical Training Bodies, the Medical Council of Ireland and each clinical site that employs
doctors in the int system in Ireland;
• HSE Workforce Planning, Analysis and Informatics Unit (WPAI);
• The Postgraduate Medical Training Bodies;
• The Medical Council of Ireland – Medical Council Workforce Intelligence Report;
• The National Clinical Programme (NCPs) linked to each specialty;
• International medical workforce datasets;
• International health research groups (i.e. Health Workforce Australia and equivalents in the NHS, New
Zealand and Canada)
Variations between datasets (e.g. DIME and the Medical Council of Ireland) are not unexpected and therefore the
results from the different sources are not identical. These limitations of the datasets are due to variations in the
time-point of data collection, differences in the variables collected (e.g. whole-time equivalents (WTE) versus
headcount), differences in the definitions of some variables (e.g. less than full-time versus part-time), absence of
variable values (i.e. missing data) in datasets, and varying quality of data between sources, among other things.
DIME gathers data on those working in a clinical capacity only and includes permanent, non-permanent and agency
doctors.
In general, information in this report that has been sourced from DIME. At the time of data analysis, the consultant
data set was approximately 90% complete and was checked for accuracy. Some variables have a lower completion
rate than others (e.g. hours worked per week) and the quality of information varies between clinical sites. NDTP
aims to further develop this information and analysis on consultant posts, workforce demographics and working
arrangements (and how these variables interact with each other), so that recruitment, retention and replacement
challenges in healthcare settings, and medical specialties, can be better identified.
8
4.2 DEMAND ESTIMATES
A large volume of research and work related to estimating the future demand for consultants and specialists
across medical specialties in Ireland has been carried out by our stakeholders in recent years. Approaches taken to
determining demand range from consideration of multiple factors driving demand for consultants and specialists
including population and epidemiological changes, new models of care, changing technologies etc. to simple
international comparisons. While NDTP has considered all information submitted to it in determining the future gap
between supply and demand for consultants and specialists, it isrecommended that a more integrated and consensus
driven approach to medical workforce planning is applied in the future. This would likely involve consideration of
multiple drivers of change, using a multidisciplinary panel of experts to come to an objective consensus agreement
around how many consultants, specialists and postgraduate trainees are required to meet future demand. Demand
and supply estimates may be analysed over a number of different scenarios.
4.3 PRIVATE SECTOR
Data on the private sector medical workforce has been sourced from the Medical Council of Ireland. Some
stakeholders have identified issues with the accuracy of the data on the private sector and as such, these figures
should be interpreted with care. Data on the private sector workforce represents consultants and specialists
working exclusively in private health services. The data is self-reported by clinicians and specialists, and completion
of the information on work in the private sector is optional.
9
5 PROFILE OF THE CURRENT MEDICAL CONSULTANT AND SPECIALIST WORKFORCE
In order to get a profile of the number and type of medical consultants and specialists working
in the Irish health care system currently, data were analysed from the following sources:
• The Doctors Integrated Medical E-System (DIME)
• The Medical Council of Ireland
• HSE Workforce Planning, Analysis and Informatics – Workforce Census Data
This analysis informed the baseline, current day understanding of the number and type of these medical doctors
working across both the public and private health care systems. As already mentioned in Section 1, the remit of
NDTP is to develop medical workforce plans to service the population health needs of the Irish population as a
whole, accepting that data limitations outlined in Section 4 apply to the modelling.
Currently in Ireland there are approximately:
• 3,100 consultants working in the public sector with an estimated additional 500 consultants/specialists
working exclusively in the private sector
• In addition, there are 3,989 GPs, 88 Public Health Medicine specialists, 91 Ophthalmologists and 79
Occupational Medicine specialists working across the country both public and privately
• There are approximately 4,000 trainees working in the Irish healthcare system and an additional 2,400
non-training NCHDS working in publicly funded services
This means that there are estimated to be in the region of 7,850 medical consultants, GPs and other medical
specialist doctors as well as 6,400 NCHDs working in Ireland, across both public and private settings.
The following Table 5.1 provides the estimated consultant/ specialist medical workforce summary by medical
discipline while Tables 5.2, 5.3 and 5.4 demonstrate the current consultant/ specialist workforce composition, across
Medical, Surgical and other specialties.
These tables give a breakdown of the workforce by the following variables:
• Approved posts i.e. posts approved by the HSE Consultants Appointments Advisory Committee (CAAC)
• Publicly funded consultant/specialist workforce (in both headcount, HC, and whole time equivalent, WTE,
terms)
• Privately funded consultant/specialist workforce (in both headcount, HC, and whole time equivalent,
WTE, terms)
• The estimated overall whole time equivalent working rate (WTE rate)
• Gender
• Full time working patterns
• Tenure
• Proportion of the workforce over 55 years and therefore likely to retire in the next 10 years
10
Table 5.5 provides an overview of the number of higher specialist trainees across each specialty as provided by each
Training body.
It is important to note the following in relation to Tables 5.1-5.5
• Approved public sector post numbers are from the DIME database of consultants held in NDTP as per
post approvals at CAAC (DIME, 2018)
• HC employed is the number of consultants working in publicly funded services (DIME, 2018). Please note
that HC also includes those that are employed but may have had their contractual hours reduced to 0 for a
period of time, for example maternity leave or secondment to another post
• WTE employed is the total number of consultants working in whole time equivalent terms (DIME, 2018)
• Private sector data (those exclusively working in the private sector) is accessed through the Medical
Council of Ireland and supplemented with the public sector WTE rate to infer the total number whole time
equivalent consultants working in the private sector numbers (Medical Council, 2017)
• The totals are the total for the private and public sector consultant numbers, for both HC and WTE
• The data on gender, full time working and tenure are sourced from DIME, (2018) and the Medical Council
of Ireland (2017)
• Data on age is accessed via DIME, (2018) and the Medical Council of Ireland (2017) and is used to infer
coming retirements over the next 10 years. Also included in modelling is an expected proportion of
consultants leaving the workforce for reasons other than retirement
• The total HST number, is that for all trainees in the higher specialist training programme for the specialty
(Training Bodies, 2018)
Table 5. 1 Estimated Consultant and Specialist Workforce in Ireland 2017/2018
Specialty
Approved Posts
Public HC
Public WTE
Private Only HC
Total Public And Private HC
Inferred WTE Rate
Total Estimated Public and Private WTE
% Female
% Full Time
% Perma- nent
% > 55 years
Anaesthesiology 398 382 342 59 441 0.9 396.9 33% 90% 88% 29%
Critical Care 24 18 18 - 18 1 18 53% 94% 84% 16%
Total Anaesthesiology & Critical Care 422 400 360 59 459 0.9 414.9 33% 90% 88% 29%
Paediatrics & Neonatology 201 199 176 56 255 0.88 225 50% 84% 87% 24%
Psychiatry 466 433 391 51 484 0.90 437 53% 85% 79% 25%
Obstetrics and Gynaecology 158 160 148 23 183 0.93 170 45% 84% 90% 40%
Diagnostic/Clinical Radiology 242 248 239 21 269 0.96 258 35% 89% 90% 28%
Radiation Oncology 23 25 22 4 29 0.88 26 52% 95% 91% 30%
Emergency Medicine 108 100 86 7 107 0.86 92 21% 84% 73% 25%
Pathology 275 242 227 22 262 0.94 246 55% 89% 95% 25%
Total Medicine 698 749 668 118 867 0.88 763 35% 87% 87% 29%
Total Surgery 568 551 493 127 678 0.93 631 14% 87% 90% 30%
HC Head Count
WTE Whole Time Equilivant
HST Higher Specialist Training
11
Table 5. 2 Estimated Breakdown of the Consultant and Specialist Workforce in Ireland 2017/2018 - Medical Specialties
Medical Specialty
Approved Posts
Public HC
Public WTE
Private Only HC
Total Public And Private HC
Inferred WTE Rate
Total Estimated Public and Private WTE
% Female
% Full Time
% Perma- nent
% > 55 years
Cardiology 45 49 45 20 69 0.92 64 6% 88% 92% 31%
Cardiology (General) * 21 21 21 - 21 0.99 21 10% 96% 91% 48%
Total Cardiology 66 70 66 20 90 0.95 85 8% 92% 92% 40%
Clinical Genetics 5 4 4 0 4 1 4 50% 100% 100% 75%
Clinical Pharmacology 4 6 4 - 6 0.67 4 17% 73% 67% 50%
Clinical Pharmacology * 1 1 1 0 1 1 1 0% 100% 100% 0%
Total Clinical Pharmacology 5 7 5 0 7 0.714 5 17% 77% 86% 43%
Dermatology(including Paediatrics) 38 40 37 15 55 0.93 51 70% 95% 98% 20%
General Medicine * 54 75 64 20 95 0.85 81 35% 94% 75% 30%
Endocrinology * 52 56 50 6 62 0.9 58 32% 92% 80% 23%
Gastroenterology * 65 69 63 16 85 0.91 78 30% 86% 88% 21%
Rheumatology* 39 42 35.34 16 58 0.84 48.62 30% 69% 81% 41%
Respiratory Medicine * 61 67 58 10 77 0.86 67 21% 86% 85% 19%
Nephrology * 35 35 35 - 35 1 35 31% 91% 91% 83%
Genito Urinary Medicine 5 5 2 - 5 0.43 2 75% 38% 75% 23%
Geriatric Medicine 110 112 106 3 115 0.94 108 39% 88% 82% 50%
Infectious Diseases * 17 17 15 - 17 0.9 15 53% 87% 88% 17%
Medical Oncology 41 43 37 4 47 0.86 40 40% 92% 93% 18%
Metabolic Diseases 1 1 1 - 1 1 1 0% 100% 100% 16%
Neurology 45 46 39 6 52 0.84 44 30% 71% 87% 19%
Neurophysiology 10 10 10 - 10 0.98 10 30% 90% 100% 15%
Palliative Medicine 37 38 32 1 39 0.85 33 67% 78% 90% 10%
Rehabilitation Medicine 12 12 9 1 13 0.75 10 50% 67% 92% 23%
Acute Medicine – dual posts in the main ** 166 0%
* Denotes a specialty within which a consultantusually has a commitment to the General Medicine rota as well as to their own specialty
** Note on Acute Medicine
• For the nine Model 4 (tertiary) hospitals - Recommendation: 6 - 8 WTE acute physicians who work 50% or more in Acute Medical Units (AMU) and Medical Short Stay Units (MSSU) • For the fourteen Model 3 (general) hospitals - Recommendation: 8 – 12 hospital physicians, all with specialist interests and also all providing an acute medicine service on a
combined 1:8 to 1:12 rota in the AMAU • For the ten Model 2 (local) hospitals - Recommendation: 6physicians all with specialist interests and also all providing cover to the Medical Assessment Unit
12
Table 5.3 Estimated Breakdown of the Consultant and Specialist Workforce in Ireland 2017/2018 - Surgical Specialties
Medical Specialty/ Sub-specialty
Approved Posts
Public HC
Public WTE
Private Only HC
Total Public and Private HC
Inferred WTE rate
Total Estimated Public and Private WTE
% Female
% Full Time
% Perma- nent
>55 yrs
Cardiothoracic surgery 19 19 18.9 3 22 0.99 21.78 17% 95% 95% 26%
General Surgery 200 187 165.3 21 208 0.88 183.04 12% 88% 84% 35%
Neurosurgery 15 13 12.9 4 17 0.99 16.83 8% 84% 100% 54%
Ophthalmic Surgery 44 49 39.5 18 67 0.79 52.93 31% 77% 83% 27%
Oral & Maxillo-Facial Surgery 12 8 8 3 11 0.94 10.34 0% 78% 78% 22%
Otolaryngology 58 56 47.7 9 65 0.87 56.55 20% 83% 88% 38%
Paediatric Surgery 6 8 8 1 9 1 9 13% 88% 100% 25%
Plastic Surgery 28 29 26.8 15 44 0.93 40.92 21% 90% 93% 21%
Trauma and Orthopedic Surgery 107 107 96.5 44 151 0.84 126.84 10% 84% 89% 28%
Urology 46 42 40.9 9 51 0.98 49.98 10% 93% 90% 26%
Vascular Surgery 33 33 28.4 N/A 33 0.95 31.35 12% 94% 91% 25%
13
Table 5. 4 Estimated Breakdown of the Consultant and Specialist Workforce in Ireland 2017/2018 - Other Specialties
Specialty
Total HC
Total WTE Rate (inferred)
Total WTE
% Female
% Full Time
% Perma- nent
% > 55 years
% Female
% Full Time
% Perma- nent
% > 55 years
Occupational Medicine* 79 0.82 65 0.54 0.7 - 0.38 33% 90% 88% 29%
General Practice** 3989 0.83 3311 0.5 0.7 - 0.37 53% 94% 84% 16%
Medical Ophthalmology 91 0.83 76 0.57 0.67 - 0.41 33% 90% 88% 29%
Public Health Medicine*** 88 0.84 74 0.78 0.72 1 0.47 50% 84% 87% 24%
* Awaiting update on Occupational Medicine from RCPI
** A Note on General Practice For the purpose of this report and in line with the report ‘Medical Workforce Planning, Future Demand for General Practitioners 2015-2025’ (HSE, 2015), we
refer to all doctors providing GP services (whether onthe specialist division of the Medical Council of Ireland’s register or not) as GPs. It should be noted that itis an aspiration of the Department of Health and the HSE that all doctors working inGeneral Practice should be on the specialist division of the register. At the time that specialist registration was introduced by the Medical Council of Ireland in 2007, not all eligible GPs availed of the opportunity to register; these GPs are on the general division of the register. At the time of publication of the 2015 report, approximately 35% of doctors who worked as GPs were not specialist trained or had not grandfathered on to th e specialist division of the register when eligible.
*** This is the total Public Health medical workforce, not just those working for the HSE but also those in the Department of Health, the academic sector and organisations such as SafeFood
14
15
Table 5.5 Total Number of HST Trainees per Specialty 2018
Total Number
Medicine
HST Cardiology 47
HST Clinical Genetics 1
HST Clinical Pharmacology 2
HST Dermatology 22
HST Endocrinology & DM 25
HST Gastroenterology 45
HST Genito-Urinary Medicine 2
HST Geriatric Medicine 48
HST Infectious Diseases 22
HST Medical Oncology 22
HST Nephrology 29
HST Neurology 32
HST Palliative Medicine 15
HST Pharmaceutical Medicine 1
HST Rehabilitation Medicine 4
HST Respiratory Medicine 49
HST Rheumatology 24
Total Medicine 392
Anaesthesiology Anaesthesiology 147
Surgery
HST Trauma and Orthopaedic Surgery 57
HST Plastic Surgery 27
HST Cardiothoracic Surgery 7
HST Otolaryngology 20
HST Urology 21
HST Paediatric Surgery 3
HST General Surgery 61
HST Ophthalmology 19
HST Neurosurgery 8
HST Oral and Maxillo Facial Surgery 2
HST Vascular Surgery 7
Total Surgery 232
Emergency Medicine HST Emergency Medicine 46
Occupational Medicine HST Occupational Medicine 12
Paediatrics
HST General Paediatrics 130
HST Neonatology 2
HST Paediatric Cardiology 3
Total Paediatrics 135
Pathology
HST Chemical Pathology
HST Clinical Microbiology 18
HST Haematology 27
HST Histopathology 42
HST Immunology 4
Total Pathology 94
Radiology
HST Radiation Oncology 16
HST Diagnostic Radiation 99
Total Radiology 115
Obstetrics & Gynaecology HST Obstetrics and Gynaecology 83
General Practice HST General Practice 368
16
Consultant
posts
approved 203ı
CSCSTs: 2482
+170 GP
+ 3 Occ Med
+ 12 PHM
Approved3 HSTposts: 546
Filled4 HSTposts: 497
Approved BST posts: 756
Filled BST Posts: 7345
Approximately
650 Irish graduates
are currently occupying
non training posts in Ireland
Intern posts: 734
Psychiatry
HST Adult Psychiatry 86
HST Child and Adolescent Psychiatry 29
Total Psychiatry 115
Public Health Medicine HST Public Health 33 Overall Total 1770
Figure 5.1 outlines, for the year 2018 to 2019, the trajectory of posts created for medical doctors in training through
to gaining a consultant post opportunity within the publicly funded health care system. Consultant posts approved
below are averaged as there has been variation in approvals over the years. In 2018/2019 approximately 248 doctors
received their CSCST and were eligible to take up a consultant post within the publicly funded health system. A total
average of 203 consultant posts were approved by the CAAC annually inferring that there were no consultant post
opportunities available to almost 20% of newly qualified specialists.The research suggests that a significant
proportion of doctors who do not secure a consultant post will emigrate rather than wait for new consultant post
opportunities to arise(Humphries et al. 2017). Figure 5.1 Indicates that many doctors who commence training, exit the
system along the way. Of the 2,400 estimated non-training scheme doctors working in the health service, we know
that approximately 22% are Irish medical school graduates who may have gone on to train at BST and/or HST level.
These doctors are therefore potentially eligible to complete training and go on to take up a consultant post in their
chosen specialty. On average, over the past 5 years, 203 consultant posts have been approved at the CAAC while
data from DIME for indicates that 127 in 2018 and 157 in 2019 new or replacement permanent/ CID posts were filled.
See Figure 5.1 below.
1 Consultant approved posts denotes new and replacement posts averaged over the past 5 years 2 This figure refers to those who have completed higher specialist training and are eligible to apply for consultant posts 3 Refers to the total number of training posts approved as deemed necessary by the HSE based on WFP projections 4 The difference between the approved and filled posts are predominantly due to a lack of
capacity to increase training numbers within training schemes. A lack of suitable candidates or insuThcient applications received account for a small proportion of the difference
5 This figure includes a small number of trainees repeating year 1 of training
FIGURE 5.1 Training Pathway THROUGH To CONSULTANT Posts
17
6 INTERNATIONAL COMPARISONS
In determining the appropriate demand for medical consultants and specialists in Ireland, it is informative to
look at how Ireland compares across international jurisdictions with similar models of health service delivery and
postgraduate training. The weaknesses of benchmarking domestic data against international data are known and
include
a. A lack of contextual consideration;
b. Assumptions that the international standard is best practice; and,
c. Potential complacency should the domestic value equal that of the international value.
In the developing this, NDTP has reviewed the workforce composition in a number of key comparable countries,
England, Scotland, Australia and New Zealand. The results of this review are outlined in tables 6.1, 6.2 and 6.3. Please
note that the populations used for these calculations were based on the year of the data available.
Table 6.1 Comparison of Ireland with international jurisdictions Total ratio per 100,000 of the Population
Specialty Ireland England Scotland Australia New Zealand
Canada
Population used for calculations 4.8 m 55.9 m 5.4 m 23.9 m 4.7 m 37 m
Emergency Medicine 2.2 3.7 4.5 5.7 5.1
Anaesthesiology 9.5 12.4 14.4 16.8 16.4
Intensive Care Medicine 0.4 1.2 0.4 2.4 1.9
Total Anaesthesiology and ICM 9.9 13.6 14.8 19.2 18.3
General Practice 71 76 82.4 114 73.6
Obstetrics & Gynaecology 3.8 4.6 4.7 6.6 6.2
Paediatrics 5.4 7.1 5.8 6.4 7.9
Psychiatry 9.8 7.3* 13*
12.3 12
Pathology 5.3 5.2 6.2 5 6.1
Radiology 6 6.2 6.4 7.4 9.7
Radiation Oncology** 0.6 - - 1.3 - 1.5
Occupational Medicine 1.5 - - 0.8 1.2
Public Health Medicine 1.8 Not Comparable 2 1.5 3.7
Ophthalmology – Medical 1.9 - - 3.6 2.9
* Figure for Psychiatry in England comes from the Royal college of Psychiatrists 2017 workforce census available at
https://www.rcpsych.ac.uk/docs/default-source/improving-care/workforce/workforce-census-report-2017.pdf
** Radiation Oncology is comparable with Australia and Canada but not the other countries, this is because of differences in the service delivery models
*** Public Health is not comparable with England because of differences in how specialists are employed
18
Table 6.2 Comparison of Ireland with international jurisdictions (Medical Specialties) Total ratio per 100,000 of the Population
Specialty Ireland England Scotland Australia New Zealand
General Medicine 2 1.6 2.3 2.8 -
Cardiology 1.4 2.6 2.3 4.4 -
Cardiology ( General) 0.4 - - - -
Total Cardiology 1.9 2.6 2.3 4,4 -
Clinical Genetics 0.08 0.3 0.4 0.2 -
Clinical Pharmacology 0.1 - - - -
Dermatology 1.2 1.3 1.5 1.9 1.4
Genito Urinary Medicine 0.1 0.5 0.5 - -
Geriatric Medicine 2.4 2.7 3.7 2.2 -
Endocrinology 1.4 1.4 1.6 2 -
Gastroenterology 1.8 2.5 2.1 2.8 -
Infectious Diseases 0.4 0.3 0.6 1 -
Medical Oncology 1 0.9 0.5 1.9 -
Metabolic Diseases 0.02 - - - -
Neurology * 0.9 1.6 1.3 1.9 0.8
Neurophysiology 0.2 0.2 0.2 - -
Palliative Medicine 0.8 0.7 0.8 0.8 1.1
Rehabilitation Medicine 0.3 0.3 0.4 1.6 0.5
Rheumatology 1.2 1.2 1.2 1.1 -
Respiratory Medicine 1.6 2.1 2.4 2 -
Nephrology 0.7 1.1 1.2 1.5 -
* Discrepancies may exist between international jurisdictions where Neurologists
cover vascular neurology (Stroke) and those that do not
Table 6.3 Comparison of Ireland with international jurisdictions (Surgical Specialties) Total ratio per 100,000 of the Population
Specialty Ireland England Scotland Australia New Zealand
Cardiothoracic Surgery 0.5 0.7 0.6 0.6 0.6
General Surgery 4.3 4.5 5.2 5.5 5.7
General + Vascular 4.9 - - - -
Neurosurgery 0.4 0.6 0.6 0.9 0.5
Ophthalmic Surgery 1.4 2.6 2.4 - 2.9
Oral & Maxillofacial Surgery 0.3 0.7 0.6 0.4 0.5
Sources of International Data:
• NHS England (2019)- NHS Workforce Statistics September 2019 available from: https://files.digital.nhs.uk/5B/6FCE1C/ NHS%20Workforce%20Statistics%2C%20September%202019%20Doctors%20by%20Grade%20and%20Specialty. xlsx and https://digital.nhs.uk/data-and-information/publications/statistical/general-and-personal-medical-services
• NHS Scotland (2019); https://www.isdscotland.org/Health-Topics/Workforce/Publications/data-tables2017.asp?id=2484#2484 and https://www.isdscotland.org/Health-Topics/General-Practice/Publications/2018-03-06/2018-03-06-PCWS2017-Report. pdf (GP-data)
• Australia - Health Workforce Australia Medical practitioners overview 2015 data tables available from: https://www.aihw.gov.au/reports-data/health-welfare-services/workforce/data
• NZ– New Zealand Medical Workforce 2016 database available from: https://www.health.govt.nz/
19
7 DEMAND FOR CONSULTANTS AND SPECIALISTS IN IRELAND
Having established the current baseline of the medical workforce, the next step is to give a high level overview of the
gap between the current supply of consultants and specialists in the health service across Ireland both now and in
the future, in line with stakeholder informed demand to meet future patient need.
The process of assessing future demand for doctors has led to the identification of a number of drivers of change
to the future of the medical workforce across all areas of medicine. These are high level environmental factors
determined by stakeholders to have a strong and driving influence on changes in future health service demand,
thereby impacting the demand for consultant and specialist services over the coming decade and thereafter.
The most commonly referred to drivers of change to the demand for consultant and specialists are outlined in
Figure 2.2 i.e. population, epidemiology, service reconfiguration, policy and legislation, eHealth and technology
advances, new models of care and new ways of working, levels of current service utilisation and levels of current
unmet demand for services. Sláintecare represents current Government policy that will drive change across the
medical workforce as a whole and has been integrated into estimated demand for GPs in particular. Ongoing work
in the area of service reconfiguration for Public Health will also align with the requirements of Sláintecare. These
estimates are not yet fully developed and will be included in this report when complete.
Table 7.1 provides a more granular breakdown of the views shared by stakeholders since 2014 in relation to the major
drivers of change impacting the future of health care and medical workforce demand.
Table 7.1 Drivers of Change to the Future Health and Medical Workforce
Chronic disease prevalence and management
New models of care delivery to include more care in the community, hub and spoke models of care delivery
Population and epidemiological change
Hospital Groups, Community Healthcare Organisations
Integrated services developments
Unmet demand for health services to include recruitment and retention of staff
Impact of service redesign and population changes on future workload
New staThng models e.g. specialty cross-over & nursing task allocation
Innovations in drugs, diagnostics, interventions and other health technologies
Consultant-delivered service vs. consultant led service
Patient safety
European Working Time Directive compliance
Economic factors e.g. access to funding, economic boom/bust scenarios
Flexible working arrangements
Access to services for patients
Migration
Government Legislation
In determining the future demand for consultants and other medical specialists in Ireland to 2028, stakeholders
were tasked with assessing future workforce demand having considered the impact of these drivers on for example,
population health, patient presentations, and service delivery systems.
20
7.1 ESTIMATED DEMAND FOR MEDICAL CONSULTANTS AND SPECIALISTS IN IRELAND
Table 7.1.1 details the estimated demand for consultants and specialists in Ireland over the next 10 years. These
estimates are derived from a number of different sources including, National Clinical Programmes (NCPs),
Postgraduate Medical Training Bodies, HSE Primary Care Division, HSE Mental Health Division and other specialty
representative bodies. The projections outlined in a number of Government policy documents were reviewed
including the Report of the National Task Force on Medical StaThng (Department of Health, 2003), and the Vision for
Change (Department of Health, 2006), as well as the updated policy for publicly funded mental health services. While
some of these reports are not current, the recommendations within the reports have been partially implemented
over the last 5 years and are therefore deemed relevant to informing medical workforce planning today. Data to align
the GP workforce with universal free GP care is used herein to indicate how the workforce may need to be resourced
to align with some elements of Sláintecare.
The models of care adopted by the NCPs are of particular relevance in informing medical workforce demand
estimates and future workforce projections. NDTP has worked with a number of NCPs to determine the projected
demand for the medical workforce based on the predicted new models of care, to support new planned service
developments. Examples include the new model of care for Paediatrics and Neonatology and the new draft model
of care for Anaesthesia.
Table 7.1.1 outlines the current consultant and specialist workforce estimates, in comparison with predicted demand
to 2028. These demand estimates are based on information from major workforce planning stakeholders (Appendix
A provides a breakdown of sources per specialty) and are presented in line with the following:
• The estimates account for demand across both public and private sectors i.e. for the population of Ireland
as a whole and not just for those using HSE funded services
• Projections to 2028 use the latest CSO population projectionswhich infer an increase in the population
to 5.1 million (Central Statistics OThce, 2018). These wereaccessed online at www.cso.ie, under the M2F2
scenario, as advised by the CSO
• Figures are presented as headcount, as opposed to the WTE rates in earlier tables
• Where WTE recommendations were given to NDTP in relation to the future demand for specialists, these
were converted to HC estimates using WTE information from the DIME database or using assumptions.
For more information on the ratio of consultants/ specialists per head of population, recommended by the Hanly
Report (Department of Health, 2003) and the estimated demand for specialists and consultants,as outlined by
NDTPs stakeholders, see table 7.1.1.
21
Table 7.1.1 Future Consultant/ Specialist Demand Estimates to 2028
Specialty Total HC Current Hanly to 2028 based on ratio per head of population
Total Demand to 2028 HC Range based on stakeholder perspectives and the Hanly Report recommendations, 2003
Anaesthesiology 441 - 566
Critical Care ŧ 18 - 82
Total Anaesthesiology & Critical Care 459 612 648
Paediatrics & Neonatology 255 270 454
Psychiatry 484 765 TBD*
Obstetrics and Gynaecology 183 250 275
Diagnostic / Clinical Radiology 269 372 423
Radiation Oncology 29 31 50
Occupational Medicine 79 - 160-233**
General Practice 3989 - 4794-5649***
Ophthalmology 91 - 128
Public Health Medicine 88 - Awaiting^
Emergency Medicine 107 127 178
Pathology 262 357 392.5
Medical Specialties
Cardiology^^ 90 117 110
Clinical Genetics 4 10 15
Clinical Pharmacology 7 20 29
Dermatology 55 59 64
General Medicine 95 88 88
Endocrinology 65 88 105
Gastroenterology 85 88 152
Rheumatology 42 88 91
Respiratory Medicine 77 88 171
Nephrology 35 79 40
Genito Urinary Medicine 5 5 5
Geriatric Medicine 115 102 144
Infectious Diseases 17 58 63-64
Medical Oncology 47 58 99
Metabolic Diseases 1 - 5
Neurology 52 44 65-89
Neurophysiology 10 13 24
Palliative Medicine 39 58 109
Rehabilitation Medicine 13 28 42-46
Acute Medicine 166 - 216-290
Surgical Specialties
Cardiothoracic surgery 22 29 33
Vascular surgery 33 - 74
General and Vascular^^ 241 239 258
Neurosurgery 17 21 31
Ophthalmic Surgery 67 86 88
Oral and maxillofacial surgery 11 34 35
Otorhinolaryngology 65 71 72
Paediatric Surgery 9 16 17
Plastic Surgery 44 50 52
Trauma and Orthopaedic Surgery 151 204 231
Urology 51 64 74
22
ŧ NDTP are currently working on a specialty specific report for Critical Care/ Intensive Care Medicine that will outline demand for future consultants and training requirements. The current report will be updated with the revised figures once that process is complete
* Work is ongoing between NDTP and stakeholders relevant to Psychiatry to determine the demand estimates for Psychiatry
** Range from RCPI and Irish Society of Occupational Medicine
*** Range from expert group and accounts for the roll out of free GP care to different age cohorts of the population
^ Awaiting numbers from HSE as per new model of service delivery for Public Health Medicine
^^ A workforce planning exercise is being undertaken in Cardiology; therefore this demand estimate is likely to change and will be updated once this exercise is complete
^^ Demand estimates from stakeholder included General and Vascular as the submission pre-dated full implementation of specialty recognition for Vascular surgery and the associated training programme. More research is required to accurately reflect demand for these specialties in their own right
Table 7.1.2 Future Consultant/ Specialist Demand Estimates to 2028 % Increase
Acute Medical Specialties Current HC Proposed Future HC Gap HC % Increase
Anaesthesiology 441 566 125 28%
Critical Care 18 82 64 356%
Total Anaesthesiology and Critical Care 459 648 189 41%
Paediatrics & Neonatology 255 454 199 78%
Psychiatry 484 TBD - -
Obstetrics and Gynaecology 183 275 92 50%
Diagnostic / Clinical Radiology 269 423 154 57%
Radiation Oncology 29 50 21 72%
Emergency Medicine 107 178 71 66%
Pathology 262 393 131 50%
Medical Specialties
Cardiology 90 110 20 22%
Clinical Genetics 4 15 11 275%
Clinical Pharmacology 7 29 22 314%
Dermatology 55 64 9 16%
General Medicine 95 88 -7 -7%
Endocrinology 65 105 40 62%
Gastroenterology 85 152 67 79%
Rheumatology 42 80 38 90%
Respiratory Medicine 77 171 94 122%
Nephrology 35 40 5 14%
Genito Urinary Medicine 5 5 0 0%
Geriatric Medicine 115 144 29 25%
Infectious Diseases 17 64 47 276%
Medical Oncology 47 99 52 111%
Metabolic Diseases 1 5 4 400%
Neurology 52 89 37 71%
Neurophysiology 10 24 14 140%
Palliative Medicine 39 109 70 179%
Rehabilitation Medicine 13 44 31 238%
Total Medical 854 1437 583 68%
Surgical Specialties
Cardiothoracic surgery 22 33 11 50%
General ( inclusive of Vascular) Surgery 241 258 17 7%
Neurosurgery 17 31 14 82%
Ophthalmic Surgery 67 88 21 31%
Oral and maxillofacial surgery 11 35 24 218%
23
Across specialties, stakeholders raised concerns around estimating the workforce demand and the
implications of reconfiguration of services, or lack thereof, as well as the capacity within the healt h
service to accommodate the numbers of postgraduate medical trainees deemed to be required to meet
future demand. A major concern highlighted was the urgent need to create new consultant posts and to
stem emigration among newly qualified specialists.The National Acute Medicine Programme (NAMP)
also referenced a need for more generalists and less emphasis on specialism.
Otorhinolaryngology 65 72 7 11%
Paediatric Surgery 9 17 8 89%
Plastic Surgery 44 52 8 18%
Trauma and Orthopaedic Surgery 151 231 80 53%
Urology 51 74 23 45%
Total Surgical 678 891 213 31%
Overall Total - acute hospital based specialties (excludes Psychiatry*)
3096 4749 1653 53%
Overall Total - all medical specialties (excludes Public Health and Psychiatry*)
7255 10323 3068 42%
Acute Medicine - mid point of range** 166 253 87 52%
Overall Total GP - mid-point of range 3989 5249 1260 32%
Overall Total GP - universal free GP Care 3989 5649 1660 42%
* Psychiatry and Public health have been excluded from the overall totals to avoid skewing the results as demand estimates are not yet available for these specialties yet
** Those contributing to Acute Medicine have a commitment to another specialty, this has been accounted for in the figures displayed for specialties with a commitment to GIM and displayed separately to infer the increase required for Acute Medicine as informed by The National Acute Medicine Programme (NAMP)
Acute Medicine is unique in that it is comprised of consultants working across different medical specialties, whereby
consultants have a contractual commitment to the Acute Medicine rota in specific hospitals. The commitment of
consultants to Acute Medicine are captured within the demand estimates presented for each relevant specialty.
It is; however, acknowledged that more work needs to be done to ensure that requirements of consultants with a
commitment to the Acute Medicine roster are being met appropriately. More information on the breakdown of demand
for consultants working in Acute Medicine, see Appendix B.
The demand estimates for General Practice are based on analysis of demand outlined in the report Medical Workforce
Planning: Future Demand for General Practitioners 2015-2025 (HSE National Doctors Training and Planning, 2015). The
demand for GPs is based on rolling out free GP care to the under 18’s and over 70’s as well as universal free GP care.
Estimates were derived through updating of the results of the 2015 report, using the latest CSO population projections
to 2028, which infer an increase in the population to 5.1 million, and recommended ratios of GPs per head of population
across different scenarios (Central Statistics OThce, 2018). See www.hse/doctors for more information. In this way GP
demand estimates are aligned with Sláintecare. In order to allow for comparisons with other Government publications
regarding the demand for medical specialists an analysis of the percentage increase required per specialty is outlined
in Table 7.1.2. Demand estimates used in this table are from specialty stakeholders, mainly NCPs and Postgraduate
Medical Training Bodies. For specialities with a demand range, the mid-point is used. As can be seen from this table an
overall and estimated 42% increase in consultant/ specialist numbers is required to 2028 to meet stakeholder demand
estimates. It is important to note again that demand estimates are not derived using a standardised methodology. For
a limited number of specialties e.g. Emergency Medicine, Paediatrics, Palliative Medicine, Anaesthesia and Critical
care and others, estimates are based a new model of service delivery. Some specialties use international benchmarks
while others consider population change, service utilisation change and staThng required to meet unmet demand as
per waiting lists, vacancies, onerous rostering among other things.
24
7.2 ANALYSIS OF THE GAP BETWEEN THE CURRENT AND FUTURE SUPPLY
AND DEMAND FOR CONSULTANTS AND SPECIALISTS IN IRELAND
Given the large volume of data associated with a multi-specialty review of workforce demand and supply, a simple gap
analysis only permitted a high level estimate of the future demand and supply of consultants and specialists. In order
to project the supply and demand for consultants and specialists over the next 10 years, a simplified version of the
statistical forecasting model developed by the Expert Group on Future Skills Needs and Solas was used (Behan et al.
2009). Going forward, NDTP will however continue to carry out more detailed reviews of individual specialties as per
previous research reports and medical workforce reviews published on www.hse.ie/doctors.
It is important to highlight that variables used to estimate the supply of doctors include adjustment for part-time and
full-time working patterns, as well as the gender breakdown of doctors. In addition, the model takes into account the
expected numbers of doctors retiring and the assumed proportion of those exiting the workforce for reasons other
than retirement, alongside health service data on the number of doctors entering the workforce post completion of
specialist training.
Within the statistical forecasting model, the inflow of overseas doctors was set to zero in order to isolate the domestic
supply and assess the extent to which the national education and training system can meet estimated future demand.
In this way, entrants into the workforce are based on the number of doctors who complete postgraduate specialist
training and are eligible to enter on to specialist division of the Medical Council of Ireland’s register. Exits, on the other
hand, are based on all those doctors leaving the health system for retirement and other reasons. This is in line with the
prudent approach taken by FAS/ Solas and the Expert Group on Future Skills Need (Behan et al. 2009).
A number of further assumptions underpin the workforce planning methodology as follows:
• In order to estimate thedemand for consultants and specialists over the next 10 years, stakeholder-
informed recommendations are used. As already stated, these estimates represent the views of
stakeholders rather than those of NDTP
• Variables used to estimate the supply of consultants and specialists include the number of doctors
currently delivering services (headcount and WTE); the part-time and full-time working adjustment rates,
projected retirements and gender breakdown of doctors
• Supply and demand projections are typically converted to a ratio of consultants/ specialists to the
population. CSO population projections are used to determine demand. These projections are based
on data from the Census of the population using the M2F2 scenario. This scenario infers a reduction in
the Total Fertility Rate (TFR) and moderate migration per annum. Data accessed from the CSO in 2018
inferred a growth in the population to approximately 5.1 million people up to 2028 (Central Statistics
OThce, 2018)
• Demand estimates have been received from the NCPs and where available from Postgraduate Training
Bodies. This can lead to more than one demand estimate. If deemed appropriate, the recommendations
from the Hanly report (Department of Health, 2003) are used to imply demand. Table 7.1.1 provides a
detailed overview of demand estimates used per specialty
• Within the statistical forecasting model, the inflow of overseas specialists is set to zero to isolate the
domestic supply of consultants/ specialists and assess the extent to which the national education and
training system can meet estimated future demand
• Entrants into the consultant/specialist workforce are based on the number of doctors who complete
postgraduate training and enter on to the specialist division of the Medical Councils of Ireland’s register
• The number of consultant/ specialists retiring and the assumed proportion of those exiting the workforce
for reasons other than retirement are also estimated
25
• In general, emigration among consultants/ specialists is not accounted for in the scenarios outlined,
although the model can be manipulated to assess the impact of different rates of emigration. See an
example for Paediatrics and Neonatology in tables 7.3.1 and 7.3.2.
• Attrition from training is based on data, where available, from Postgraduate Medical Training Bodies
• All graduates of specialist training enter the workforce, with a WTE ratio estimated for the consultant/
specialist workforce as of 2018
• WTE rates are kept static over the projection period and can be manipulated to infer the impact of
changes in working patterns
7.3 RESULTS
The workforce planning projections outlined in the following tables can be interpreted as follows:
• Employment represents the number of consultant/ specialists required to bring the workforce in line with
the demand for specialists, as per stakeholder perspectives, by 2028
• Expansion demand represents the number of additional specialists required year on year to bring the
workforce to the stakeholder recommended number of consultant/ specialists in the workforce by 2028
e.g. employment requirements 2019 minus employment 2018 = expansion demand
• Replacement demand represents the number of consultants/ specialists exiting the workforce and is
based on projected retirements and ‘other’ leavers as per the workforce configuration
• Recruitment requirement represents the total number of consultants/ specialists required as per a
summation of expansion demand and replacement demand
• Graduate supply represents those expected to complete higher specialist training and enter the
workforce
• Gap to supply represents the difference between the recruitment requirement and the newly registered
(graduate) supply
• A minus sign indicates an oversupply of specialists as per the gap between supply and demand over the
10-year period
In order to illustrate how the model works, an example for the specialty of Paediatrics and Neonatology is outlined
in Tables 7.3.1 and 7.3.2.
7.3.1 Worked Examples For Paediatrics And Neonatology
Table 7.3.1a Scenario A Headcount Demand for Consultants in Paediatrics and Neonatology – Stakeholder Informed
Consultants Headcount
2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 Totals
Required employment 255 275 295 315 335 355 375 395 415 434 454
Expansion demand 20 20 20 20 20 20 20 20 19 20 0 199
Replacement demand 11 11 11 11 12 12 12 12 12 12 0 116
Recruitment requirement 31 31 31 31 32 32 32 32 31 32 0 315
Graduate supply 21 33 24 29 32 32 32 32 32 32 0 299
Gap to graduate supply 10 -2 7 2 0 0 0 0 -1 0 0 16
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Table 7.3.1b WTE Demand for Consultants in Paediatrics and Neonatology – Stakeholder Informed
Consultants - WTE 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 Totals
Required employment 224 242 260 277 295 312 330 348 365 382 400
Expansion demand 18 18 18 18 18 18 18 18 17 18 0 175
Replacement demand 10 10 10 10 10 10 10 10 10 10 0 102
Recruitment requirement 28 28 28 28 28 28 28 28 27 28 0 277
Graduate supply 18 29 21 26 28 28 28 28 28 28 0 263
Gap to graduate supply 9 -1 7 2 0 0 0 0 -1 0 0 14
• Required employment represents the increase in doctors to 2028 to meet patient demand by 2028. This
demand estimate is a composite of estimates submitted to NDTP by the National Clinical Programme for
Paediatrics and Neonatology, and is based on the implementation of the model of care for the specialty.
This infers an increase in the total number of consultants working across the public and private sectors
from 255 headcount consultants in 2018 to 454 headcount consultants in 2028
• Expansion demand required employmentrepresents the number of additional consultants (approximately
20) required annually to bring the workforce to the demand estimate of 454 by 2028
• Replacement demand represents the number of consultants exiting the workforce due to retirement, and
for other reasons i.e. approximately 11-12 per year to 2018
• Recruitment requirement represents the total number of consultants required as per expansion demand
and replacement demand i.e. a total of 31-32 approximately year on year to 2028
• Graduate supply represents those specialists expected to complete specialist training and enter the
workforce, i.e. from 21 to 33 annually, should the most recent intake number of trainees on the HST
programme for Paediatrics be kept constant to 2028
The results of this gap analysis infers that, by 2028, a shortage of around 16 consultants may be realised should a
decision be made to increase the consultant Paediatrics and Neonatology workforce from the current 255, across
both the public and private systems, to approximately 454 consultants by 2028, with a parallel training intake of 32
trainees from 2019 on. In order to bridge the gap between supply and demand, the intake of trainees into Paediatric
Higher Specialist Training should potentially be increased from 32 to approximately 35. It is again important to note
that the proposed demand estimates represent the perspectives of the stakeholders, rather than those of NDTP.
Tables 7.3.1a and 7.3.1b represent scenario A whereby there is no emigration among newly qualified Paediatricians
and Neonatologists in Ireland and all of those doctors eligible for specialist registration are available to take up
consultant posts. In order to model the effect of emigration, a modelling scenario B was used. Scenario B includes
an emigration rate of around 15% among newly qualified consultants/ specialists and is represented in Tables 7.3.2a
and 7.3.2b. In this case, the gap between the supply and demand for consultants/ specialists increases from a no
emigration scenario (tables 7.3.1a and 7.3.1b) to a scenario where there is 15% emigration amoung newly qualified
specialists (tables 7.3.2a and 7.3.2b), this sees the undersupply rise from 16 (HC) to 61 (HC).
This analysis underlines the significant impact of emigration among newly qualified consultants/ specialists on the
availability of doctors to take up consultant posts.
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Table 7.3.2a Scenario B Headcount Demand for Consultants in Paediatrics and Neonatology – Stakeholder Informed – 15% Emigration among newly qualified specialists
Consultants Headcount
2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 Totals
Required employment
255 275 295 315 335 355 375 395 415 434 454
Expansion demand
20 20 20 20 20 20 20 20 19 20 0 199
Replacement demand
11 11 11 11 12 12 12 12 12 12 0 116
Recruitment requirement
31 31 31 31 32 32 32 32 31 32 0 315
Graduate supply 18 28 20 25 27 27 27 27 27 27 0 254
Gap to graduate supply
13 3 11 7 4 4 4 5 4 5 0 61
Table 7.3.2b Scenario B WTE Demand for Consultants in Paediatrics and Neonatology – Stakeholder Informed – 15% Emigration among newly qualified specialists
Consultants - WTE
2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 Totals
Required employ- ment as per S1
224 242 260 277 295 312 330 348 365 382 400
Expansion de- mand
18 18 18 18 18 18 18 18 17 18 0 175
Replacement demand
10 10 10 10 10 10 10 10 10 10 0 102
Recruitment requirement
28 28 28 28 28 28 28 28 27 28 0 277
Graduate supply 16 25 18 22 24 24 24 24 24 24 0 224
Gap to graduate supply
12 3 10 6 4 4 4 4 3 4 0 53
28
Gap Remaining: 2,536
Plus Entrants: +4,010 Less exits: -3,478
Future Demand in 2028 =10,323
Additional demand to 2028: +3,068
Consultant/Specialist Workforce 2018: 7,255
Gap Remaining: 646
Plus Entrants: +2,320 Less exits: -1,313
Future demand: 4,749
Additional demand: +1,653
Current: 3,096
Gap Remaining: 1,674
Plus Entrants: +1,660 Less exits: -2,074
Future demand: 5,249
Additional demand: +1,260
Current: 3,989
Results of Gap Analysis All Medical Specialists and Consultants
Figures 7.1 to 7.3 outline the overall estimated number of specialists and consultants employed across both the public
and private sectors in 2018, the approximate future demand for consultants and specialists in 2028 and the gap
between the current and future required number of specialists and consultant. This gap analysis takes into account
exits from the workforce (due to retirement and for other reasons) as well as entrants into the systems (CSCSTs)
should the 2018 training intake remain constant over the coming years. Gender and working patterns are also built
into these estimates. Similarly, as per Figures 7.2 and 7.3, the gap analyses indicate the need for a significant increase
in both acute hospital consultants and GPs by 2028.
FIGURE 7.1 RESULTS of Gap Analysis All Medical Specialists and CONSULTANTS (exCLUDING Psychiatry& PUBLIC Health)
FIGURE 7.2 RESULTS of Gap Analysis ACUTE Hospital Based CONSULTANTS (exCLUDING Psychiatry and PUBLIC Health)
FIGURE 7.3 RESULTS of Gap Analysis General Practitioners
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8 TRAINING IMPLICATIONS ACROSS MEDICAL SPECIALTIES
The estimates for demand and future workforce capacity show a future workforce gap, for the majority of specialties,
which is exacerbated by emigration factors. In line with the principle, that the national training pipeline should aim
to provide suThcient numbers of consultants and specialists from domestic supply, it is necessary to consider the
changes that would be required to meet future demand. Table 8.1 shows the training intake into higher specialist
training in 2018, together with the levels that would be required over the next 4-5 years (depending on the length of
the training programme) in order to meet stakeholder demand estimates.
Table 8.1 Projected Training Needs to Meet Stakeholder Demand Estimates
Specialty Training Intake 2018 HST Total Training needs to meet stakeholder demand estimates
Anaesthesiology and Critical Care ŧ 35 40
Paediatrics & Neonatology 32 35
Psychiatry 55* TBD**
Obstetrics and Gynaecology 13 21 - 22
Diagnostic / Clinical Radiology 26 34
Radiation Oncology 4 3 - 4
Occupational Medicine 3 18 - 31
General Practice 193 375 - 518***
Ophthalmology 0 9 - 10
Public Health Medicine 5 TBD
Emergency Medicine 13 14
Pathology 22 30
Cardiology 7 4
Clinical Genetics 0 2
Clinical Pharmacology 0 3 - 4****
Dermatology 4 2
Endocrinology 6 8 - 9
Gastroenterology 9 10 - 11
Rheumatology 6 6 - 7
Respiratory Medicine^ 11 13^^
Nephrology 6 3 - 11^^^
Genito Urinary Medicine 0 n/a
Geriatric Medicine 12 18 - 19
Infectious Diseases 3 4 - 6^^^^
Medical Oncology 5 7 - 8
Metabolic Diseases n/a^^^^^
Neurology^ 6 4 - 5
Neurophysiology n/a^^^^^^
Palliative Medicine 4 3 - 12^^^^
Rehabilitation Medicine 2 5
Acute Medicine$ 49 - 123^^^^
Cardiothoracic 1 3
General and Vascular 12 17$$
Neurosurgery 1 4 - 5
Ophthalmic Surgery 7 5
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Oral and maxillofacial surgery 0 TBC
Otorhinolaryngology 5 5
Paediatric Surgery 0 1 - 2
Plastic Surgery 3 0
Trauma and Orthopaedic Surgery 8 17 - 18
Urology 3 5
Vascular Surgery 2 7 - 8
ŧ Supra-Specialty Training in Critical Care/ Intensive Care Medicine(ICM) lasts for 2 years above completion of base specialty HST and can be completed via two pathways:
• Pathway 1: Trainees in Anaesthesia, Emergency Medicine or General Internal Medicine can commence training to become a specialist in CC/ ICM during HST. This can be part of Special Interest training within the Anaesthesia training programme or as an out of programme year for the other specialties. A second year of training completed post-CSCST completes the specialist training in ICM
• Pathway 2: Alternatively two years of training can be completed post-CSCST for those who have completed training in Anaesthesia, Emergency Medicine or General Internal Medicine
Training in ICM is managed through the Joint Faculty of Intensive Care Medicine of Ireland (JFICMI). According to the Intensive Care Consultant Manpower positioning paper, 2018 an annual intake of 4.2 trainees is required to meet a demand estimate of 82.This figure requires more detailed modelling, the focus of a current specialty specific review.
* Based on exit projections from training body, not all trainees finish within 3-4 years therefore undersupply may be larger than cited here
** Work is ongoing between NDTP and stakeholders relevant to Psychiatry to determine the demand estimates and subsequently the training needs to meet these estimates for Psyciatry
*** Depending on further roll out of free GP care to under 12s and over 70s and to all – no emigration built into estimates
**** Clinical Pharmacology demand to meet mid-point in terms of demand range
^ Not quantified through gap analysis
^^ To meet ITS recommendation – update to RCPI 2014 estimate
^^^ To meet RCPI ’14 rec approx. 5-6 per year but to meet Hanly 10-11 per year
^^^^ Depending on service reconfiguration / rotas
^^^^^ Metabolic Diseases is not currently a postgraduate medical training programme in Ireland. As part of Clinical Genetics training there is a 6 month adult Metabolic Diseases rotation in the current curriculum; but to be eligible an Irish or UK Clinical Genetics graduate will need to do a year of post CSCST in Adult Metabolic disease
^^^^^^ Neurophysiology is not currently a postgraduate medical training programme in Ireland. The NCP for Neurology have proposed a joint training programme with Neurology
$ There is no training programme specifically for Acute/ General medicine as a standalone specialty, training must be done in conjunction with another specialty. The breakdown in such jointly trained posts should be approx. 50:50 for Acute Medicine : Other specialty
$$ General and Vascular Surgery were originally estimated by stakeholders to be combined. However, Vascular Surgery is more recently a recognised specialty in its own right and cursery estimates of training demand are approximately 7-8 intake per year. More research is need to more accuarately reflect demand for this specialty
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9 CONCLUSION
In recent years, NDTP medical workforce planning projections have ensured an evidence-based approach to planning
the postgraduate medical training intake on an annual basis. This report, being a high level, multi-specialty review
of demand and supply for consultants and specialists, will allow for expansion in evidence-based decision making
across all medical specialties. It also has the potential to serve as a baseline to work towards a more fit-for-purpose
medical workforce operating in an integrated system of healthcare delivery, as outlined in Sláintecare.
The overall findings of this report infer that, across the health system as a whole, there is a need for a considerable
increase in the numbers of medical consultants/ specialists and trainees. Accounting for stakeholder informed
consultant/specialist demand estimates and the results of modelling supply and demand for these doctors, we
potentially need a 42% increase in consultant and specialist numbers by 2028. This estimated increase includes
an increase of approximately 53% of consultants working in acute hospital based specialties. Depending on the
successful implementation of Sláintecare and the roll out of ‘Universal free GP care’, a 42% increase in GPs may be
required. Should free GP be rolled out to all those under the age of 18 and over the age of 70, then a 32% increase in
GPs may be required.
In order to meet this level of staThng in the system, an almost 38% increase in trainees across all specialties,
excluding General Practice, over the next 5 years will be required. General Practice is unique in its requirements
for a substantial growth in trainee numbers in order to move towards policy changes advocated within Sláintecare.
General Practice numbers are estimated to have a growth requirement from today’s number of 3,989 to a future
number of 5,649, to roll out universal free GP care. This would require an increase from approximately 200 to over
500 trainees in General Practice over the next 5 years, not accounting for doctor emigration. Estimates do not
factor in more nurse-led care in the community which may reduce this demand estimate somewhat. More research
is needed in this area once plans for primary care and General Practice developments are more fully formed, in line
with Sláintecare policy. Indeed this may apply to all specialties in time.
Estimates should (but do not always) allow for changing population health profiles, unmet demand for services, new
models of service delivery, high levels of upcoming retirements in some specialties and increasing flexible and less
than full time working arrangements. Increasing training numbers should correspond with a reduction in the number
of non-training scheme doctors in order to improve patient care through better ratios of trainees to consultants
and through a more consultant-delivered service. Currently from analysis of data from the Medical Council, it is
estimated that over 600 non-training scheme NCHDs could potentially take up training posts.
9.1 HOW FINDINGS COMPARE WITH OTHER HEALTH SERVICE DEMAND RELATED REPORTS
It is useful to compare the demand estimates derived from this report with those derived from both the ESRIs report
‘Projections of Demand for Healthcare in Ireland 2015 to 2030’ (Wren et al. 2017) and the Health Service Capacity
Review 2018 (Department of Health, 2018). Table 9.1 outlines and compares the main findings of all 3 reports. The
ESRI projections are based on projected changes in the population, broken down by genderand age structure of the
population along with measures of healthy ageing. Projections are not based on the introduction of new models of
service delivery. Of note is the fact that GP baseline data accounts for approx. 3,000 GPs rather than the almost
4,000 GPs delivering services as per Irish Medical Council data in the Health Service Capacity Review and in the
medical workforce planning projections herein. While there are in the region of 3,000 GPs on the Specialist Division
of the Medical Council Register, there are almost 1,000 more doctors working as GPs on the General Division. A
decision was taken in 2015 by an Expert Panel on GP workforce planning, that all of these doctors should be
considered part of the GP workforce for the purpose of medical workforce planning (HSE National Doctors Training
and Planning, 2015).
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The HealthService Capacity Review projections are based on:
1. ‘No change in service delivery model’
2. ‘Change to bring about an integrated care model with a focus on a continuum of care, whereby emphasis
on disease prevention, early detection and management are to the fore, with care being delivered at the
lowest possible level of acuity, closest to the home’
As such, a number of projected demand estimates are proposed in the Health Service Capacity Review. Table 9.1
outlines the projected demand for health services as per the ESRI and HealthService Capacity Review reports as
well as the findings of this medical workforce planning report. While these estimates are not directly comparable
due to the drivers for demand considered, metrics and methodologies used, they are nevertheless interesting to
consider in the context of future demand for healthcare in Ireland.
Table 9.1 Demand Estimate Comparisons
PA Consulting DoHHealth Service Capacity Review Projected Demand to 3031 – New Model of Service Delivery
No Change in Service Delivery Model 2031
Change in Service Delivery Model 2031
AMU Beds +37% 0%
Day Cases +47% +14%
Inpatient Beds +56% +20%
ACC Beds +79% +79%
General Practitioners +39% +29%
ESRI Projected Demand Estimates to 2030 Change in Age Structure and Measures of Healthy Ageing
Projected Increase in Service Utilisation2030 – excludes unmet demand
Projected Increase in Service Utilisation 2030–includes low level unmet demand
Inpatient bed days +32% to+37% +36%
Inpatient discharges +24 to +30% +28%
Day patient discharges +23% to +28% +29%
ED attendances +16% to +26% -
Outpatient attendances +21% to +29% +30%
Private Inpatient bed days +28% to +32% -
Private inpatient admissions +20% to +25% -
Private day patient admisssions +24 to +28% -
General Practitioner visits +20% to +27% +22%
NDTP Medical Workforce Planning Demand Estimates
Projected Demand 2028
Acute hospital specialties +53%
General Practitioners +32% to +42%
As can be seen, the Health Service Capacity Review projects a demand for an increase in inpatient beds of between
20% and 56%, depending on whether the status quo prevails or a complete reform of services is successfully
implemented. The corresponding increase for day cases is between 14% and 47% depending on whether or not
reforms take place. The demand for GPs is projected to be somewhere between 29% and 39%, again depending on
reconfiguration of services. The ESRI project an increase in inpatient bed days of up to 37% and an increase in day
patient discharges by up to 29%. The ESRI also project an increased demand for GP visits ofup to 27%.
If we use inpatient beds and day case demand as a proxy for demand for consultants, then the estimated demand
for an increase of 53% of acute hospital-based consultants and specialists outlined in this report is lower, albeit
fairly well aligned with the Health Service Capacity Review scenario whereby the status quo prevails i.e. a 56%
33
increase. Estimates proposed within the ESRI report are not as well aligned, perhaps due to differences in variables
considered in the demand estimation process. As mentioned in general (but not always), working conditions,
international benchmarks and new models of care were factored into demand estimates of NDTP stakeholders,
along with population change and unmet demand.
The demand for GPs outlined in this report is fairly well aligned with the ‘no change’ scenario outlined within the
Health Service Capacity Review i.e. an increased demand of between 32%-42% proposed herein versus increased
demand of 39% should the status quo remain unchanged, as outlined in the health Service Capacity Review.
GP demand within the Health Service Capacity Reviews’ reform scenario however, does not align with NDTP estimates of
demand should universal free access to GP care be implemented. Demand estimates as per the implementation of a fully
integrated health service outlined in the Health Service Capacity Review are below those outlined in the demand estimates
for this report i.e. a 29% increase in demand as opposed to NDTPs’ estimate of a 42% increase in demand for GPs.
The ESRI estimates of GP demand based on population change align well with those proposed in the Health Service
Capacity Review’s reform scenario and NDTPs scenario based on free GP care to the under 18s and over 70s i.e.
respective estimates of increases up to a 27%, 29% and 32%. Of note is the fact that NDTP and ESRI estimates
did not consider the impact of task reallocation from, for example, GPs to practice nurses or other health care
professionals and more chronic disease management in the community. More research is recommended in this area.
While workforce planning estimates may be higher than those outlined for some scenarios in both the Health
Service Capacity Review and the ESRI report, it is important to keep in mind that demand for consultants and
specialists takes into account the need for more appropriate numbers to ensure better staThng across specialties.
While the analysis of stakeholder estimates of the future demand for consultants and specialists was in the main
high level, all stakeholder estimates aimed to address working conditions within the hospital and community setting
including heavy workloads, low levels of staThng, long waiting lists and onerous rostering arrangements. A number of
specialty demand estimates considered the implementation of a new model of service delivery along with changes
in the population and service utilisation, more care in the community, consultant-delivered care and more integrated
care delivery systems. Other stakeholders used international benchmarks alone to project demand.This report did
not solely rely on quantitative data to estimate future demand. All stakeholders were given the opportunity to voice
and validate the demand estimates for specialist doctors across specialties.
9.2 ENSURING A SELF-SUSTAINABLE MEDICAL WORKFORCE
The approach taken to estimating the future demand for trainees and consultants within this report assumes that
Ireland will be self-sustainable in its production of medical doctors and therefore reliance on overseas doctors will
decline as more trainees come out of the Irish postgraduate medical training system. Ireland has a responsibility
to adhere to the WHO Code on ethical recruitment in health care (World Health Organisation 2010, 2011) and this
approach supports such a policy. However, in order to do this a focused approach to reducing doctor emigration
will be essential. Work can also be undertaken to bring Irish trained specialists back into the system and therefore
potentially offset this against the number of estimated required trainees.
9.3 MORE CONSULTANT-DELIVERED CARE, LESS NON-TRAINING NCHDS
As stated in the introduction to this report, Ireland has among the lowest numbers of specialist doctors per head
of population in the OECD (OECD, 2019). It is Government policy that the health system should continue to move in
the direction of more consultant-delivered care. A consultant-delivered service for Ireland infers more consultants
present at the front line delivering care to patients. An extensive research study carried out by the United Kingdom’s
34
Academy of Medical Royal Colleges (2012) on the benefits of more consultant-delivered care found that ‘numerous
reviews by expert clinicians have concluded that patients have increased morbidity and mortality when there is a
delay in the involvement in their care of consultants across a wide range of fields’. Consideration of expert reviews
and the international research by the Academy deduced that ‘there is evidence across a wide range of medical
fields that consultants deliver better patient outcomes and improved eThciency of care…the consistency of the
association between consultant involvement and improved outcomes across many studies in many specialties is
compelling’ (AOMRC, 2012 P.6).
The conclusions of the study were that the benefits of consultant-delivered care include:
• A high level of clinical competence ensuring rapid and appropriate decision making
• Improved outcomes for patients which follow from appropriate diagnosis and the most clinically skilled
interventions
• Skilled judgement and performance leading to the most effective working and more eThcient use of
resources through, for example, length of stay reduction or fewer unnecessary investigations
• GP’s access to the opinion of a fully trained doctor
• Patient expectation of access to appropriate and skilled clinicians and information in a timely fashion
Across health services today, it is accepted that more consultant-delivered care is paramount to effective service
delivery and that the huge over-reliance on NCHDs to deliver services has implications for patient safety, service
eThciencies and costs (Department of Health 2003). A ratio of between 1 and 1.2 NCHDs per consultant has been cited as
appropriate to achieving safer, more eThcient and cost effective care(HSE National Doctors Training and Planning, 2016).
As mentioned previously, increasing training posts should correspond with a reduction in the number of non-training
scheme posts. This can be done by converting non-training scheme doctor posts to training posts, which will benefit
thesystem through ensuring more appropriately trained doctors and a pipeline to meet the future demand for
consultants. The caveat here however remains the need to fund a large increase in consultant posts.
It is proposed herein that there is susbstantial potential to expand the HSE’s International Medical Graduate Training
Initiative (IMGTI), an international medical trainee exchange programme which benefits the Irish healthcare system
through the provision of trainee doctors delivering care where needed over a 2-3 year period. Upon completion of
the programme doctors return with their acquired skills to deliver services within their home country.
If consultant numbers are to grow in line with the projections outlined in this
report, then the following considerations must underline this growth:
1. Along with increasing trainee numbers, consideration must be given to the reduction in non-training posts.
Currently there are approximately 2,400 non-training scheme doctors in thepublicly funded health service.
A proportion (650 approximately) of these posts could potentially be converted to training posts. This
would move the system closer to achieving a more consultant-delivered health service with a higher ratio
of trainees to consultants than exists today.This is in line with Government and WHO policy as well as the
recommendations of the Hanly report (Department of Health, 2003). A pilot project in Waterford University
Hospital is underway to determine if increasing consultant and training posts, while decreasing non-training
scheme doctor’s posts, can improve patient care and working conditions within the hospital. This project
could lay the foundations for future implementation of a more consultant-delivered service nationally.
2. Further considerations to ensure improved patient care include regulation of non-training scheme NCHD
posts, improved supports while maintaining the focus on reducing numbers, the introduction of Medical
Associate Programme for these doctors as well as expansion of the International Medical Graduate
Training Initiative.
3. Much needs to be done to retain Irish medical graduates so that the trend of training doctors for export
35
is reversed. A situation whereby trainees nearing completion of specialist training had the option to
apply for a known upcoming consultant post would likely result in better retention of medical graduates
and more consultant-delivered care. This would further align the workforce with policy objectives.
Addressing the two-tier system of consultant pay is also required to ensure better recruitment and
retention of specialist trained doctors.
4. More consultants in the system in general, and in some cases working an extended day and at weekends
would improve eThciencies around clinical decision making and rostering arrangements; reduce onerous
workloads, improve the medical training experience of trainees and improve patient outcomes through a
parallel reduction in non-training scheme doctors in the workforce. Patient safety is a high priority within
the HSE and a medical workforce consisting of more consultants and less non-training scheme doctors
would align with the HSE objective of making patient safety paramount.
5. More consultants in the system who are appropriately trained to reflect future population and
epidemiological healthcare demands. For example, our ageing population will demand more medical
specialists with skills to meet the care of the elderly i.e. GPs, Geriatricians, General Physicians,
Orthopaedic Surgeons, Cardiologists and so on.
6. A cost-benefit analysis of increasing consultant numbers with a reduction in the number of non-training
scheme NCHDs and considering the impact of an increase availability of consultant posts on doctor
emigration should be considered with a view to giving financial weight to the argument of increasing
consultant numbers. Engaging the Department of Public Expenditure and Reform in such an exercise would
be beneficial.
9.4 A FINAL WORD
It is important to bear in mind that the prediction of demand is not an exact science and heavily based on the views
of stakeholder bodies, including the individual NCPs and Postgraduate Training Bodies. In the developing this
report, NDTP engaged with stakeholders for all medical specialties on a number of occasions through requests for
submissions on medical workforce planning for consultant/ specialists; through meetings and a seminar, as well as
through requests for clarification on data estimates to be included in this report.
The following caveats pertaining to the staThng and training demand estimates should be noted:
1. Despite the demand for consultants/ specialists and parallel training needs, there are limitations
pertaining to the capacity within the health system to accommodate trainees in some specialties. On
occasion, Postgraduate Training Bodies and the HSE are unable to accommodate the required number of
trainees, due to lack of posts within the system. This can be due to insuThcient consultant and specialist
trainer numbers, among other things.
2. Increasing rigour in determining demand is justified to improve the process of discussion and consensus
used.
3. A critical obstacle to determining consultant and specialist doctor staThng demand remains the potential
impact of service reconfiguration.
4. While some National Clinical Programmes have developed models of care for their specialties, which
serve as a framework or strategy to inform future service developments and parallel staThng needs, not
all specialties have developed these models. As such, demand estimates can be made using estimates
submitted to NDTP by stakeholders as well as via simple international comparisons, and through other
such means, which are not as robust.
5. The transfer of tasks between and across health professionals may impact the future demand for some
consultants/ specialists. For example, increased level of nurse-led care may impact the demand in areas
such as chronic disease management.
6. There is potential for new and emerging technologies, including drugs, to impact staThng demand but this
is diThcult to predict and understand with some certainty. More research in this area is warranted.
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10 REFERENCES
Academy of Medical Royal Colleges. 2012. THE BENEFITS OF CONSULTANT-DELIVERED CARE. https://www.
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11 APPENDICES
APPENDIX A SPECIALTIES/STAKEHOLDERS ENGAGED IN THE
MEDICAL WORKFORCE PLANNING PROCESS
National Clinical Programmes
National Acute Medicine Programme
National Clinical Programme for Anaesthesia (including Paediatric Anaesthesia)
National Clinical Programme for Neurology
Critical Care Programme
National Clinical Programme for Older People
Emergency Medicine Programme
Diabetes Programme
National Clinical Programme for Radiology
National Cancer Control Programme
National Clinical Programme for Trauma and Orthopaedic Surgery
National Clinical Programme for Obstetrics and Gynaecology
National Clinical Programme for Paediatrics and Neonatology
National Clinical Programme for Palliative Care
National Clinical Programme for Ophthalmology
National Clinical Programme for Pathology
National Clinical Programme for Surgery
National Clinical Programme for Rheumatology
National Clinical Programme for Rehabilitation Medicine
Training Bodies
Royal College of Physicians of Ireland
Irish Committee on Higher Medical Training Infectious Diseases
Gastroenterology
Clinical Genetics
Clinical Pharmacology
Cardiology
Endocrinology/ Diabetes
Medical Oncology
Nephrology
Neurology
Rehabilitation Medicine
Training Bodies
Respiratory Medicine
Rheumatology
Neurophysiology
Faculty of Occupational Medicine Occupational Health Medicine
Faculty of Paediatrics and Neonatology Paediatrics and Neonatology
Institute of Obstetrics and Gynaecology Obstetrics and Gynaecology
Faculty of Public Health Medicine Public Health Medicine
Faculty of Pathology Pathology – all specialties
Royal College of Surgeons in Ireland Radiology (Diagnostic and Radiation Oncology)
Emergency Medicine
Sports and Exercise Medicine
Surgery – all specialties
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College of Anaesthesiologists Anaesthesia and Critical Care
Irish College of General Practitioners General Practice
Irish College of Ophthalmologists
Medical Ophthalmology College of Psychiatrists of Ireland
Psychiatry
HSE Divisions
HSE Primary Care
HSE Mental Health
HSE National HR
HSE Planning and Performance
HSE Public Health
Children’s Health Ireland
Specialty Representative Bodies
Irish Thoracic Society Respiratory Medicine
Irish Society of Occupational Medicine Occupational Medicine
Irish Endocrine Society Endocrinology
Irish Board for Training in Cardiovascular Medicine
Cardiology
Infectious Diseases Society Ireland Infectious Diseases
Note that where a specialty did not respond to recent requests for submissions on medical workforce planning, NDTP used data from 2014 submissions where appropriate. This was only necessary for a small proportion of specialties.
39
APPENDIX B BREAKDOWN OF DEMAND FOR CONSULTANTS
WORKING IN ACUTE MEDICINE
National Acute Medicine Programme (NAMP):
Guidance for CAAC regarding applications for consultant physician posts
Model 4 hospitals
Acute Medical Units (AMUs) are staffed by acute medicine physicians during working hours.
The NAMP recommends that:
1. When undertaking clinical duties in the AMU, consultants should be free from any other
commitments (e.g. OPD, procedural, management, etc.)
2. When consultant numbers reach 6, there should be consultant presence from 8.00am – 8.00pm, Monday-
Friday, and for 5 hours on weekends and public holidays
3. Each AMU should have a Lead Consultant Physician; this post will rotate every 2-3 years
4. Each AMU should have a Medical Short Stay Ward (MSSW) under the governance of the acute physicians;
patients should be reviewed by an acute medicine consultant on a daily basis (including weekends) in
order to facilitate early discharge and follow-up
5. Acute medicine physicians should have dedicated specialty time; this should not exceed 50% and
be consistent with colleagues in the AMU. Most current posts are weighted between 60-80% acute
medicine
6. It is envisaged that AMUs will ultimately function on a 24/7 basis; as additional consultant appointments
are made, consultant presence should be extended e.g. to 10.00pm weekdays, and pro rata at weekends
7. Specialist physicians should support the work of the AMP by providing prompt consultation, taking over
care of AMU/ SSU patients where appropriate, providing rapid access to cardiac diagnostics and
urgent outpatient slots for appropriate AMU patients.
Model 3 hospitals
Acute Medical Assessment Units (AMAUs) operate in a similar way to AMUs, but do not normally have MSSWs.
The NAMP recommends that:
1. All consultants participating in the medical on-call roster should participate in the running of the AMAU
2. When rostered to cover the AMAU, consultants should be free from any other commitments (e.g. OPD,
procedural, management, etc.) so that they are immediately available to attend the AMAU
3. The hours of opening of AMAUs varies from unit to unit; however, a consultant physician complement of
8 facilitates consultant availability for 12 hours Monday-Friday and for 5 hours on weekends and public
holidays
4. The consultant physician on-call for medicine will manage the AMAU out-of-hours
5. Each AMAU should have a Lead Consultant Physician; this post will rotate every 2-3 years
40
Model 2 hospitals
Medical Assessment Units (MAUs) have assessment beds in a defined
area and serve a clinical decision support function.
The NAMP recommends that:
1. All consultant physicians will be jointly appointed to a Model 3 or 4 hospital
2. All consultant physicians should participate in the running of the unit
3. Each MAU should have a Lead Consultant Physician; this post will rotate every 2-3 years
4. A consultant complement of 6 facilitates consultant availability for 12 hours Monday-Friday and for 5
hours on weekends and public holidays
41
NOTES
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43
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Authors:
Dr Roisin Morris, HSE NDTP Medical Workforce Planning Lead
Maeve Smith, HSE Medical Workforce Planning
National Doctors Training & Planning HSE Dublin
Copyright:
HSE – National Doctors Training & Planning 2020
Copies of this report can be obtained from:
National Doctors and Planning Health Service Executive Block 9e Sancton Wood Building Heuston South Quarter Saint Johns Road West Dublin 8
T: 076959924 E: [email protected] W: www.hse.ie/doctors